Minnesota (MN) Life Insurance Application Packet

Application For Individual Life Insurance

1. Proposed Insured

Legal Name (First, Middle Initial, Last)

Address (Street, City, State, Zip)

Social Security Number Phone

Driver’s License Number State License Issued

Email Place of Birth (State/Country)

Birth Date (MM/DD/YYYY) Age Gender Male Female

Is Proposed Insured a current member of GBU Financial Life? Yes No Preferred District

Annual Income $ Net Worth $ Marital Status Occupation Duties

Employer

Employer Address (Street, City, State, Zip)

2. Owner Check one: Insured Applicant Other (If this section left blank, Proposed Insured will be Policy Owner.)

Legal Name (First, Middle Initial, Last) Phone

Address (Street, City, State, Zip)

Social Security Number Phone

Birth Date (MM/DD/YYYY) Relationship to Proposed Insured

3. Payor (If other than Insured, please complete the following information.)

4. Additional Contact Information

Legal Name (First, Middle Initial, Last)

Address (Street, City, State, Zip)

Social Security Number Phone

Driver’s License Number State License Issued

Birth Date (MM/DD/YYYY) Age Gender Male Female

Email

Person to contact about policy if Proposed Insured, Payor or Owner cannot be located.

Legal Name (First, Middle Initial, Last)

Address (Street, City, State, Zip)

Phone Alternate Phone

Email Relationship to Proposed Insured

5. Insurance Applied For (Not all riders available on all products.)

Note: If additional space is needed, list on a separate sheet of paper. Include the Policy Owner’s signature and date.

Legal Name (First, Middle Initial, Last)

Address (Street, City, State, Zip)

Social Security Number

Relationship to Proposed Insured

Legal Name (First, Middle Initial, Last)

Address (Street, City, State, Zip)

Social Security Number

Legal Name (First, Middle Initial, Last) Address (Street, City, State, Zip)

Social Security Number

Relationship to Proposed Insured

Legal Name (First, Middle Initial, Last)

Address (Street, City, State, Zip)

Social

Application For Individual Life Insurance (continued)

10. Health/ Family History/ Lifestyle Complete 10-19 for Proposed Insured and Payor if applying for Payor Waiver Rider.

For Payor if applying for Payor Waiver

Primary Medical Care Provider

Address (Street, City, State, Zip)

Date of last visit

for last visit

What treatment was given? Or medication prescribed?

Questions 11-18 apply to anyone to be insured under this policy or under any applied for Riders.

11. Tobacco Use

12.

a) Do you currently use tobacco or nicotine products in any form, including smoking cessation products (i.e.: patches, Chantix, etc.), e-cigarettes or any vaping products?

13.

d) Has any compensation or inducement been discussed or offered in regards to this application? Yes No

e) Have you ever sold or settled a life insurance contract? Yes No

a) Have you travelled outside the United States within the past 2 years? Yes No

b) Do you intend to travel and/or reside outside of the U.S. within the next 2 years? Yes No

c) Are you a U.S. citizen? If not, do you currently have a valid U.S. permanent resident card/green card?

(If not a citizen, provide resident card details including country, type of visa, and expiration date in details section below.)

Yes No

d) Are you currently active duty military or have orders/papers to be deployed within the next 12 months? Yes No

14. In the past 5 years, do any of the following apply? Have you or any other person to be insured under this policy:

a) Plead guilty to or been convicted of driving while impaired, intoxicated, or under the influence of any drug? Yes No

Plead guilty to or been convicted of 2 or more moving violations? Yes No

Had a driver’s license suspended or revoked? Yes No

b) Had an application for insurance declined, rated, or postponed, or offered with a modification or reduced face amount, or had a health or life contract canceled, recalled, rescinded, or denied renewal?

c) Flown as a pilot, student pilot, or crew member of any aircraft? Or plan to do so in the next 24 months?

Yes No

Yes No

d) Engaged in skydiving, hang gliding, hot-air ballooning, motor sports or racing, rock climbing, bungee jumping, or heli-skiing/heli-snowboarding? Or plan to do so in the next 24 months? Yes No

e) Used or are you currently using marijuana, narcotics, intravenous drugs, cocaine, heroin, morphine, methadone, ecstasy, barbiturates, methamphetamines, hallucinogens, or any other drug or medication, including opio ids or fentanyl, not legally prescribed by a physician?

Yes No

Application For Individual Life Insurance (continued)

14. Continued

f) Used alcoholic beverages? Please provide type, frequency and amount in Question 20. Yes No

g) Plead guilty to or been convicted of a felony or misdemeanor? Do you currently have a felony or misdemeanor charge pending against you? Are you currently on probation or parole?

Yes No

h) Filed for, requested, or received disability payments or pension benefits due to an injury, sickness, or disability Yes No

15. Have you EVER been diagnosed, treated, tested positive for, or given medical advice by a member of the medical profession for:

a) Abnormal blood pressure, chest pain, coronary artery disease, abnormal EKG or other cardiac test, elevated cholesterol, stroke, Transient Ischemic Attack (TIA), peripheral vascular disease, or any other disorder or disease of the heart, blood vessels, or of the cerebrovascular system?

Yes No

b) Cancer, tumor, polyps, basal or squamous cell carcinoma, abnormal moles or lesions, dysplastic nevi, malignant melanoma, or any other malignancy, or any growth or lump that has not been evaluated by a physician? Yes No

c) Anxiety, depression, bi-polar disorder, schizophrenia, post-traumatic stress disorder, or any other mental or nervous disease or disorder?

Yes No

d) Diabetes, thyroid disorder, anemia, hepatitis, or any other blood or glandular disease or disorder? Yes No

e) Human Immunodeficiency Virus (AIDS virus) or Acquired Immune Deficiency Syndrome (AIDS)? Yes No

16. In the past 10 years, have you been diagnosed, treated, tested positive for, or given medical advice by a member of the medical professional for:

a) Auto-immune disorders, arthritis, lupus, connective tissue disease, or any injury to or disease of the bones, muscles, joints, eyes, or skin?

b) Epilepsy, seizures, brain disorder, dizziness, fainting, tremors, multiple sclerosis, paralysis, Parkinson’s, Alzheimer’s, cognitive impairment, traumatic brain injury (TBI), motor neuron disease, or any other disease or disorder of the nervous system?

c) Symptoms such as: immune deficiency, anemia, recurrent fever, fatigue, or unexplained weight loss, malaise, loss of appetite, diarrhea, fever of unknown origin, severe night sweats, unexplained or unusual infections or skin lesions, unexplained swelling of the lymph glands?

d) Received counseling or treatment for drug or alcohol abuse, or been advised by a medical professional to receive treatment or counseling for drug or alcohol abuse?

Yes No

Yes No

Yes No

Yes No

17. In the past 5 years, have you been diagnosed, treated, test positive for, or given medical advice by a member of the medical profession for:

a) Any ear, nose, throat, lung disease or disorder or any respiratory disease or disorder, including asthma, Chronic Obstructive Pulmonary Disorder (COPD), emphysema, tuberculosis, or sleep apnea?

b) Any disease or disorder of the stomach, intestines, rectum, liver, pancreas, kidney, or bladder, including ulcers, colitis, Crohn’s Disease, celiac disease or diverticulitis?

c) Any disorder of the prostate, reproductive organs, breast, menstruation, or pregnancy?

Yes No

Yes No

Yes No

18. Other than stated above, within the past 5 years, do any of the following apply? Have you or any other person to be insured under this policy:

a) Consulted, received treatment or advice from, or been prescribed medication by any other medical professional or advisor?

b) Been admitted to the hospital for any reason besides normal childbirth, or confined to a nursing home or other medical facility?

c) Had any abnormal diagnostic or screening tests; or, within the past 2 years, been advised to seek the advice of another medical specialist, have a diagnostic test, hospitalization, surgical procedure or treatment that has not been done, except those tests related to the Human Immunodeficiency Virus (AIDS virus)?

19.

a) Have any parents and/or siblings been diagnosed with cardiovascular disease, cancer, or diabetes prior to the age of 60?

b) If yes, please provide the following information:

Father Mother Brothers Sisters

Yes No

Yes No

Yes No

Yes No

Application For Individual Life Insurance (continued)

20. Details to any “Yes” answers to Questions

11-19 above.

Question Name Details

21. Additional Details, Remarks or Special Requests

If additional space is needed, please use additional sheet that is signed and dated by Policy Owner and Insured(s).

Agreement – Authorization – Acknowledgement

This authorization complies with the HIPAA Privacy rule.

I understand I may revoke this authorization at any time, except to the extent that action has been taken in reliance on this authorization. Written notice must be sent to GBU Financial Life, 4254 Saw Mill Run Blvd., Pittsburgh, PA 15227-3394 I, the Proposed Insured (and any Payor or Owner signing below), by my signature set forth hereafter

AGREE to the following:

a) All statements and answers in this application are complete and true to the best of my knowledge and belief.

b) Except as stated in the Conditional Receipt, no insurance will take effect unless the first full premium is paid and policy is delivered while the health of any Proposed Insured continues, without any material change, to be as represented in this application.

c) No agent has authority to waive any answer; otherwise modify this application; or bind GBU Financial Life, hereinafter called “Company,” in any way by making any promise or representation which is not set out in writing in this application.

d) $ has been deposited toward payment of the first premium on the policy. The terms of the Conditional Receipt received for that premium deposit are accepted.

I AUTHORIZE any physician; medical practitioner; hospital; clinic; other medical or medically related facility; to give the Company or its reinsurer(s) all information it holds that pertains to medical consultations; treatments; surgeries; and hospital confinements which relate to the physical and mental condition of myself or my minor children. This authorization also includes a pharmacy benefits manager; insurance support organization; pharmacy/government agency; insurance or reinsuring company; MIB, Inc. (“MIB”); consumer reporting agency; or any other organization; institution; or person. This authorization also includes information about drugs and alcoholism or any other non-health (non-medical) history information.

I authorize the Company or its reinsurers to release any information including my personal health information obtained to reinsuring companies; MIB; or other persons or organizations performing business or legal services in connection with my application or claim. I further authorize the Company and its reinsurers to release any information that may be otherwise lawfully required or as I may further authorize. As to this authorization, I agree that a photographic copy will be valid as the original and that it will be valid for 30 months from the date shown below. This time limit is permitted by applicable law in the state where the policy is delivered or issued for delivery.

I know examiners, reinsurers, attorneys or other medical directors may disclose such health information for purposes of underwriting, compliance, record clarification or explanation. The aforementioned parties may also disclose such information in response to litigation, summons or subpoenas. I understand that after this information is disclosed the recipient may re-disclose it resulting in loss of protection by federal regulations.

I understand that there are limitations on my right to revoke this authorization. Any action taken in reliance on this authorization will be valid if such action has been taken prior to receipt of notice of revocation. If this authorization is used to collect information in connection with a claim for benefits, it will be valid for the duration of the claim. If the law of my state so provides, my authorization may not be revoked during a contestable investigation.

I also understand that my revocation of this authorization will not result in the deletion of codes in the MIB databases if such codes are reported by the Company or its reinsurers (or the Company or its reinsurers becomes obligated to report such codes to MIB) while this authorization is in force.

I may refuse to sign this authorization and understand that my refusal to sign will affect my ability to obtain life insurance coverage.

I ACKNOWLEDGE receipt of the following notices:

a) “Notice of Information Practices” required by Public Law 91-508 and other information practices, statutes, and

b) Notification regarding MIB, Inc

I (We) declare that the Proposed Insured desires to unite with GBU members for the following reasons. (a) Financial security and fraternal benefits. (b) Charitable community involvement. (c) Share the appreciation of our members’ culture and heritage. (d) Meet any other requirements for membership established by GBU. By purchasing an insurance product from GBU Financial Life, the Proposed Insured gains automatic membership in the society including all of its rights and privileges.

GBU Financial Life is licensed to do business in this state. As a not-for-profit organization, fraternal benefit societies are not included in the State Guaranty Association. This means that fraternal benefit societies cannot be assessed for the insolvency of other life insurers or other fraternal benefit societies. By law a fraternal benefit society is responsible for its own solvency. If there is an impairment of reserves, a certificate holder may be assessed a proportionate share of the impairment. This process is described in the certificate issued by the society.

I ACKNOWLEDGE that I did not receive a sales illustration containing full disclosure at the time when I completed the life insurance application. I understand that when the policy is issued, such an illustration will be provided to me at the time the policy is delivered to me.

Fraud Warning. Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under the state law.

Dated at ______________, ___, on ________________, 20 City State

Representative’s Report

Complete the following for each juvenile application.

(Proposed Insured age 0-17).

Complete the following for each application.

a) Amount of life insurance currently in force on Applicant? $ If none, explain.

b) Number of brothers: Number of sisters: Do they all have the same amount of insurance in force as the Proposed Insured? Yes No

c) Did you see the child? Yes No

d) If less than 1 year of age, what was the birth weight? lbs. oz..

e) Amount of life insurance in force and/or requested on father. $ and mother. $

a) Have you given the Applicant the attached (Fair Credit) Notice? Yes No

b) How long have you known the Proposed Insured?

c) Have you reviewed the entire application for corrections or omissions? Yes No

d) Are you related to the Proposed Insured? Yes No

e) Was the application taken in person? Yes No

f) Do you know anything not disclosed which might affect the underwriting of this risk? Yes No

g) Is there another application currently pending; or, being submitted to any other life insurance company? Yes No

h) Has the Proposed Insured applied elsewhere for any insurance coverage within the past 6 months? Yes No

i) Is replacement of existing insurance involved in this application? If yes, submit the appropriate replacement forms. Yes No

j) Have you ordered an exam and urinalysis? Yes No

k) Have you ordered a blood profile? Yes No

l) What is your preferred GBU district?

I hereby certify that I have truly and accurately recorded on this application the information supplied to me by the Applicant. My report has been made to the best of my knowledge and belief. I know nothing detrimental about these risks that is not recorded in these papers. I recommend them for the insurance requested. I personally solicited and secured this application. I have not made or agreed to make any rebate from GBU Financial Life’s regular premium for the insurance applied.

Dated at ______________, ___, on ________________, 20 City State

Print

Signature of General Agent

Signature of Agent

Conditional Receipt

Terms and Conditions: Coverage is issued bearing the date of this receipt will become effective on the date of the application or last medical examination, whichever is later. Coverage will be provided when the following conditions are met:

1. The application and required information are received at the GBU Financial Life Home Office.

2. All persons proposed for coverage are insurable at standard rates exactly as applied for according to the rules and practices of GBU Financial Life.

3. The full first premium is paid in cash on the date of application. The maximum amount of life insurance effective under this receipt cannot exceed $100,000. This includes accidental death and pending insurance.

There will be no conditional insurance coverage, if all conditions are not met. GBU Financial Life’s liability will be limited to returning any premium submitted to GBU Financial Life with this receipt. Returning submitted premiums and this receipt are necessary if any of the following occurs: a) one or more of the receipt’s conditions have not been met exactly; or b) any Proposed Insured dies by suicide.

If the Policy is not issued exactly as applied for, it will become effective when it is delivered to and accepted by the applicant and the modal premium is paid. If the application is declined or not approved within 60 days of its completion; no insurance will have been in force. Any premium paid will be returned. No agent of GBU Financial Life has the authority to change or modify any of the provisions in this receipt.

GBU FINANCIAL LIFE

Plan

Amount Received $

ALL PREMIUM CHECKS MUST BE PAYABLE TO GBU FINANCIAL LIFE. DO NOT MAKE THE CHECK PAYABLE TO THE AGENT OR LEAVE THE PAYEE BLANK.

By Date ___________________

Signature of Agent -

Investigative Consumer Reports

Under Public Law 91-508, we are required to inform persons proposed for insurance that, as part of our regular underwriting procedure, an investigative consumer report may be obtained which will provide applicable information concerning character, general reputation, personal characteristics, and mode of living. This information will be obtained through personal interviews with your friends, neighbors, and associates.

Important Notice

The underwriting process (evaluation and classification of risks) is necessary to assure reasonable cost of insurance and provide a mechanism by which policyholders pay their fair share of the cost. In considering your application, information from various sources is considered, including your own statements, the results of your physical examination (if required), and any reports we obtain from doctors or medical facilities where you have been treated.

NOTIFICATION REGARDING MIB, Inc. (“MIB”): Information regarding your insurability will be treated as confidential. GBU Financial Life or its reinsurers may, however, make a brief report thereon to the MIB. The MIB is a not-for-profit membership organization of insurance companies operating an information exchange on behalf of its members. The MIB may also release information in your file to another MIBmember company to whom application may be made for life or health insurance coverage; or, a benefit claim is submitted.

Upon receipt of a request from you, MIB will arrange disclosure of any information it may have in your file. Please contact the MIB at 866-692-6901. If you question the accuracy of information in MIB’s file; you may contact MIB and seek a correction in accordance with the procedures set forth in the Federal Fair Credit Reporting Act. MIB’s information office address: 50 Braintree Hill Park, Suite 400, Braintree, MA 02184-8734.

GBU Financial Life or its reinsurers may also release information in its file to other insurance companies to whom you may apply for life or health insurance; or, to whom a claim for benefits may be submitted. Information for consumers about the MIB may be obtained at its website www.mib.com

THIS NOTIFICATION MUST BE GIVEN TO THE PROPOSED INSURED BEFORE THE APPLICATION IS COMPLETED.

Important Notice Required By Minnesota Insurance Law

DEFINITION

IF YOU INTEND TO REPLACE COVERAGE

REPLACEMENT is any transaction where, in connection with the purchase of New Insurance or a New Annuity, you LAPSE, SURRENDER, CONVERT to Paid-Up Insurance, Place on Extended Term, or BORROW all or part of the policy loan values on an existing insurance policy or an annuity.

(See reverse side for DEFINITIONS.)

In connection with the purchase of this insurance or annuity, if you have REPLACED or intend to REPLACE your present life insurance coverage or annuity(ices), you should be certain that you understand all the relevant factors involved.

You should BE AWARE that you may be required to provide EVIDENCE OF INSURABILITY and

(1) If your HEALTH condition has CHANGED since the application was taken on your present policies, you may be required to pay ADDITIONAL PREMIUMS under the NEW POLICY, or be DENIED coverage.

(2) Your present occupation or activities may not be covered or could require additional premiums.

(3) The INCONTESTABLE and SUICIDE CLAUSE will begin anew in a new policy. This could RESULT in a CLAIM under the new policy BEING DENIED that would otherwise have been paid.

(4) Current law MAY NOT REQUIRE your present insurer(s) to REFUND any premiums.

(5) It is to your advantage to OBTAIN INFORMATION regarding your existing policies or annuity contracts from the insurer or agent from whom you purchased the policy or annuity contract.

(If you are purchasing an annuity, clauses (1), (2), and (3) above would not apply to the new annuity contract.)

CAUTION

If after studying the information made available to you, you decide to replace your existing life insurance or annuity with our policy or annuity contract, you are urged not to take action to terminate or alter your existing coverage or annuity(ides) until after you have been issued the new policy or annuity contract, examined it and found it to be acceptable to you. If you should terminate or otherwise materially alter your existing coverage or annuity(ies) and fail to qualify for the life insurance for which you have applied, you may find yourself unable to purchase other life insurance or be able to purchase it only at substantially higher rates.

THE INSURANCE OR ANNUITY I INTEND TO PURCHASE FROM _ ____ INSURANCE CO. MAY REPLACE OR ALTER EXISTING LIFE INSURANCE POLICY(IES) OR ANNUITY CONTRACT(S).

The following policy(ies) or annuity contract(s) may be replaced as a result of this transaction: Insurer as it appears on the policy or contract Policy or Contract Number as it appears on the policy or contract The

I (We) have read this notice and received a copy of it for my (our) records. I (We) have also received a copy of the written comparison of the proposed annuity contract and my existing policy/contract.

I certify that this form was given to and completed by (applicant, please print or type.) prior to taking an application and that I am leaving a signed copy for the applicant.

Agent’s Signature

Date

Agent’s Address City State Zip Code

Definitions

PREMIUMS: Premiums are the payments you make in exchange for an insurance policy or annuity contract. They are unlike deposits in a savings or investment program, because if you drop the policy or contract, you might get back less than you paid in.

CASH SURRENDER VALUE: This is the amount of money you can get in cash if you surrender your life insurance policy or annuity. If there is a policy loan, the cash surrender value is the difference between the cash value printed in the policy and the loan value. Not all policies have cash surrender values.

LAPSE: A life insurance policy may lapse when you do not pay the premiums within the grace period. If you had a cash surrender value, the insurer might change your policy to as much extended term insurance or paid-up insurance as the cash surrender value will buy. Sometimes the policy lets the insurer borrow from the cash surrender value to pay the premiums.

SURRENDER: You surrender a life insurance policy when you either let it lapse or tell the company you want to drop it. Whenever a policy has a cash surrender value, you can get it in cash if you return the policy to the company with a written request. Most insurers will also let you exchange the cash value of the policy for paid-up or extended term insurance.

CONVERT TO PAID-UP INSURANCE: This means you use your cash surrender value to change your insurance to a paidup policy with the same insurer. The death benefit generally will be lower than under the old policy, but you will not have t o pay any more premiums.

PLACE ON EXTENDED TERM: This means you use your cash surrender value to change your insurance to term insurance with the same insurer. In this case, the net death benefit will be the same as before. However, you will only be covered for a specified period of time stated in the policy.

BORROW POLICY LOAN VALUES: If your life insurance policy has a cash surrender value, you can almost always borrow all or part of it from the insurer. Interest will be charged according to the terms of the policy, and if the loan with unpaid interest ever exceeds the cash surrender value, your policy will be surrendered. If you die, the amount of the loan and any unpaid interest due will be subtracted from the death benefits.

EVIDENCE OF INSURABILITY: This means proof that you are an acceptable risk. You have to meet the insurer’s standards regarding age, health, occupation, etc., to be eligible for coverage.

INCONTESTABLE CLAUSE: This says that after two years, depending on the policy or insurer, the life insurer will not resist a claim because you made a false or incomplete statement when you applied for the policy. For the early years, though, if there are wrong answers on the application and the insurer finds out about them, the insurer can deny a claim as if the policy had never existed.

SUICIDE CLAUSE: This says that if you commit suicide after being insured for less than two years, depending on the policy and insurer, your beneficiaries will receive only a refund of the premiums that were paid.

Health Insurance Portability and Accountability Act (HIPAA) Authorization to Obtain and Disclose Information

I, the named Insured above or the Personal Representative of the above-named Insured, hereby authorize any health plan, physician, nurse, medical practitioner, practitioner group, health care professional, hospital, clinic, health care facility, laboratory, pharmacy, pharmacy benefit manager or other health care provider that has provided treatment, services or payment on my behalf within the past ten (10) years (“My Providers”) to disclose to GBU Financial Life (the ‘Recipient’) the following:

• Any and all information relating to the Insured’s health, excluding psychotherapy notes and the Insured’s insurance policies and claims. This information includes, but is not limited to, information relating to any medical consultations, treatments or surgeries, hospital confinements for physical and mental conditions, use of drugs or alcohol, drug prescriptions and communicable diseases, including HIV and AIDS, and

• Identifying information about the Insured, including the Insured’s name, address, telephone number, gender and date of birth.

This authorization to provide the information outlined above also extends to the following:

• Any insurance or reinsurance company, including, but not limited to, any company which may have provided the Insured with life, accident, health and/or disability coverage or to which the Insured may have applied for insurance coverage, but coverage was not issued,

• Any consumer reporting agency or insurance support organization,

• The Medical Information Bureau (MIB, LLC) and

• Any GBU Financial Life agents, employees and representatives.

I understand that the information obtained will be used by the Recipient to do the following:

• Underwrite my application for coverage, make eligibility risk rating and policy issuance determinations,

• Obtain reinsurance and administer coverage,

• Determine the Insured’s eligibility for benefits under and/or the contestability of an insurance policy and

• Detect fraud or abuse and for compliance activities, which may include disclosure to MIB and participation in MIB’s fraud prevention or fraud detection programs and activities.

By signing this authorization, I acknowledge that any agreements I have made to restrict my protected health information do not apply to this authorization, and I instruct any physician, health care professional, hospital, clinic, medical facility or other health care provider to release and disclose my entire medical record without restriction, except as specified above.

This authorization shall remain valid and in force for thirty (30) months following the date of my signature on the next page. Copy of this authorization is as valid as the original. I understand that I have the right to revoke this authorization in writing, at any time, by sending a written request for revocation to GBU Financial Life, Attention: GBU Underwriting Department, 4254 Saw Mill Run Boulevard, Pittsburgh, PA 15227-3394. I understand that my revocation is not effective to the extent that any of My Providers, as outlined above, have relied on this Authorization, to the extent that any action has been taken in reliance on this Authorization or to the extent that GBU Financial Life has a legal right to contest a claim under an

insurance policy or the policy itself. I understand that any information that is disclosed pursuant to this authorization may be redisclosed and no longer covered by federal rules governing privacy and confidentiality of health information.

I understand that My Providers may not refuse to provide treatment or payment for health care services if I refuse to sign this authorization. I further understand that if I refuse to sign this authorization to release my complete medical record, GBU Financial Life may not be able to process my application or if coverage has been issued, may not be able to make any benefit payments. I acknowledge that I have received and reviewed a copy of this authorization.

Signature of Proposed Insured Date

Describe the nature of the Personal Representative’s authority over or relationship to the Proposed Insured

Notice and Consent for Blood, Saliva and/or Urine Testing Which May Include AIDS Virus (HIV) Antibody/Antigen Testing

Insurer GBU FINANCIAL LIFE

Address 4254 Saw Mill Run Blvd Pittsburgh, PA 15227 -3394

To determine your insurability, the Insurer named above (the Insurer) has requested that you provide a sample of your blood, saliva and/or urine for testing and analysis. All tests will be performed by a licensed laboratory.

Tests may be performed to determine the presence of antibodies or antigens to the Human Immunodeficiency Virus (HIV), also known as the AIDS virus. The HIV antibody test that we perform is actually a series of tests done by a medically accepted procedure. The HIV antigen test directly identifies AIDS viral particles. These tests are extremely reliable. Other tests which may be performed include determinations of blood cholesterol and related lipids (fats) and screening for liver or kidney disorders, diabetes and immune disorders.

All test results will be treated confidentially. They will be reported by the laboratory to the Insurer. When necessary for business reasons in connection with insurance you have or have applied for with the Insurer, the Insurer may disclose test results to others involved in the underwriting and claims review process. Your test results will not be disclosed to your agent or broker. If the HIV test is positive, the results will be reported to the local health department of the state Department of Health, and if the Insurer is a member of the Medical Information Bureau (MIB, LLC), the Insurer may report the results in a generic code signifying only nonspecific blood test abnormalities. If your HIV test results are normal, no report will be made to MIB, LLC. Other tests results may be reported to the MIB, LLC in a more specific manner. The organizations described in this paragraph may maintain the test results in a file or data bank. There will be no other disclosure of test results or even that the tests have been done except as may be required or permitted by law or as authorized by you.

If your HIV test results are normal, no routine notification will be sent to you. If the HIV test results are other than normal, the Insurer or your designated licensed medical professional will contact you. The Insurer may also contact you if there are other abnormal test results which, in the Insurer’s opinion, are significant. The Insurer may ask you the name of a licensed medical professional to whom you may authorize disclosure and with whom you may wish to discuss the results

Positive HIV antibody/antigen test results do not mean that you have AIDS, but you have a significantly increased risk of developing AIDS or AIDS-related conditions. Federal medical authorities have concluded that persons who are HIV antibody/antigen positive should be considered infected with the AIDS virus and capable of infecting others.

Positive HIV antibody or antigen test results or other significant blood abnormalities will adversely affect your application for insurance. This means that your application may be declined, that an increased premium may be charged or that other policy changes may be necessary.

I have read and I understand this Notice of Consent for Blood, Saliva and/or Urine Testing Which May Include AIDS Virus (HIV) Antibody/Antigen Testing. I voluntarily consent to the withdrawal of saliva, urine or blood from me by needle, the testing of that saliva, urine or blood and the disclosure of the test(s) results as described above.

In the event of a positive HIV test result, I authorize GBU Financial Life to send the test results to the following licensed medical professional for post-test counseling and for Health Department reporting purposes:

Medical Professional's Name

Medical Professional's Address

I understand that I have the right to request and receive a copy of this Notice and Consent. A photocopy of this form will be as valid as the original.

Proposed Insured Date of Birth

Signature of Proposed Insured or Date State of Residence

Parent/Guardian

Non-Conforming Illustration/Automatic Transaction Authorization

Applicant/Owner’s Acknowledgement

I acknowledge that I did not receive a sales illustration containing full disclosure at the time when I completed the life insurance application. I understand that when the policy is issued, such an illustration will be provided to me at the time the policy is delivered to me.

Applicant’s Signature Date

Automatic Transaction Authorization (previously Check-O-Matic or EFT)

The Insurer identified above will be referred to herein as the “Company.”

GBU Member

Full Name of Bank

Account Information

Account Owner

GBU Producer Producer Number:

Type: Checking Savings Transaction: Deposit Withdrawal

Routing Number (9-digits)

Account Number

Transaction Date (Choose Day 1-28)

Legal Name (First, Middle Initial, Last)

Address (Street, City, State, Zip)

For new business initial automatic transactions, I authorize the Company to make an immediate transaction to/from the bank account listed upon receipt of this form.

I authorize the Company to

1) make electronic deposits, withdrawals and corrections to my bank account that comply with U.S. law;

2) act on this authorization until I revoke it by contacting the Company;

3) apply this authorization to any future bank accounts I may designate;

4) make administrative changes to this authorization which I request such as date and amount changes, or adding or removing contracts for automatic payment;

5) release any and all information related to this authorization to the bank account owner or third-party account owner; and

6) act upon electronic deposit, withdrawal, and administrative instructions I provide to my representative.

7) Notice of debit amounts will not be mailed. Premiums paid to GBU will appear on the bank statement.

If this form is received less than ten (10) days prior to the transaction date you entered, your authorization shall take effect on the second occurrence of the mode you have selected. You further acknowledge that if you have selected a deduction to occur on day 29, 30 or 31, the Company will make the transaction on day 28.

Bank Account Owner’s Signature Signature Date Signature (If joint account)

Accelerated Death Benefit Disclosure

Tax Consequences

The acceleration of Death Benefit offered under one of the Riders listed in this disclosure form may or may not qualify for favorable tax treatment under the Internal Revenue Code of 1986, Section 101(g) Whether such benefits qualify depends on factors such as the Insured’s life expectancy at the time benefits are accelerated If the acceleration of Death Benefit qualifies for favorable tax treatment, the benefits will be excludable from Your income and not subject to federal taxation Tax laws relating to acceleration of Death Benefits are complex. You are advised to consult with a qualified tax advisor about the circumstances under which You could receive acceleration of Death Benefits that would be excludable from income under federal law.

Receipt of acceleration of Death Benefits may affect Your family’s, Your or Your spouse’s eligibility for public assistance programs such as medical assistance (Medicaid), Aid to Families with Dependent Children (AFDC), Supplementary Social Security Income (SSI), and drug assistance programs. You are advised to consult with a qualified tax advisor and with social service agencies concerning how receipt of such a payment will affect Your family’s, Your and/or Your spouse’s eligibility for public assistance.

The Riders listed below allow the Owner of the life insurance contract to which the Rider is attached to receive a payment prior to the death of the Insured in lieu of a portion of the Death Benefit These accelerated benefits do not and are not intended to qualify as long-term care insurance.

Definitions (Other definitions will be found in the contract to which the Rider is attached.)

Accelerated Death Benefit Request (Requested Amount) – The amount of the Death Benefit that You requested to be accelerated prior to the death of the Insured If approved, this Requested Amount will reduce the Face Amount of the contract and the Death Benefit payable to the Beneficiary(ies) upon death of the Insured.

Accelerated Death Benefit Payment (Payment) – The present value of the Death Benefit that You requested to be accelerated, calculated as described in the “Present Value of the Requested Amount” section of this Rider This amount will be a fraction of the Accelerated Death Benefit Request. That fraction will depend partly on Your life expectancy based on Your qualifying condition compared to Your life expectancy at the time of issue of Your contract

Terminal Illness Accelerated Death Benefit

An Accelerated Death Benefit payment may be requested if the Insured has a Terminal Illness Terminal Illness means that the Insured has a medical condition as defined in the Rider provisions, resulting from bodily injury or disease, or both, which is expected to result in the death of the Insured within (twelve) 12 months of diagnosis

The Insured’s limited life expectancy must be first diagnosed by a Physician; and, this Terminal Illness must be demonstrated by clinical, radiological, laboratory or other evidence of the medical condition which satisfactory to Us

There is no waiting period for the Terminal Illness Accelerated Death Benefit.

The maximum amount of the Death Benefit You may accelerate because the Insured has a Terminal Illness is equal to the lesser of:

1. 95% of the Death Benefit of this contract; or

2. $500,000, including all other previously approved requests and requests currently under review on this contract

This example demonstrates a Female, Nonsmoker, Age 65, who has a fixed premium, whole life policy with Cash Value and has accelerated a portion of her Death Benefit due to a Terminal Illness

Prior to Election

After Acceleration of 90% of Death Benefit

Death Benefit = $150,000 Remaining Death Benefit = $15,000

Cash Surrender Value = $24,500 Remaining Cash Surrender Value = $2,450

Outstanding Debt = $1,000 Remaining Outstanding Debt = $100

Future Level Premiums Payable = $1,750 New Future Level Premiums Payable = $225

The Rider in this example pays a Terminal Illness Accelerated Death Benefit Payment amount of $131,000. The amount payable reflects the deduction of a $250 administration processing fee and a subtraction to reflect one year of interest.

Chronic Illness Accelerated Death Benefit

An Accelerated Death Benefit Payment may be requested if the Insured is Chronically Ill. Chronically Ill means that the Insured:

1. is unable to perform, without substantial assistance from another person for a period of at least (ninety) 90 consecutive days, at least two (2) out of the six (6) Activities of Daily Living (bathing, continence, dressing, eating, toileting, and transferring) as defined in the Rider; or

2. requires substantial supervision by another person, for a period of at least (ninety) 90 consecutive days, to protect the Insured from threats to health and safety due to Severe Cognitive Impairment as defined in the Rider

The maximum amount of the Death Benefit You may accelerate because the Insured is Chronically Ill in any (twelve) 12 month period is nineteen percent (19%) of the Death Benefit of this contract at the time of Your initial request.

If the Insured continues to be Chronically Ill, You may request an additional acceleration of the Death Benefit up to the maximum and upon annual recertification of the Insured as being a Chronically Ill individual as described in the Rider provisions An administrative fee of $100 will apply to those additional payments.

The maximum amount of the Death Benefit that may be accelerated over the lifetime of the Insured because the Insured is Chronically Ill is equal to the lesser of:

1. 95% of the Death Benefit of this contract; or

2. $500,000, including all other previous approved requests and requests currently under review on this contract.

This example demonstrates a Female, Nonsmoker, Age 65, who has a fixed premium, whole life policy with Cash Value and accelerates a portion of her Death Benefit under the Chronic Illness Accelerated Death Benefit.

The Rider in this example pays a Chronic Illness Accelerated Death Benefit Payment amount of $6,500. The amount payable reflects the deduction of a $250 administration processing fee and subtractions to reflect interest and our assessment of your future expected mortality

An Accelerated Death Benefit Payment may be requested if the Insured is Critically Ill. Critically Ill means that the Insured has been diagnosed with one or more of the following health conditions as defined in the Rider provisions: heart attack, stroke, cancer, end stage renal failure, major organ transplant, Amyotrophic Lateral Sclerosis (ALS), blindness, or paralysis.

The maximum amount of the Death Benefit You may accelerate because the Insured is Critically Ill is equal to the lesser of:

1. 95% of the Death Benefit of this contract; or

2. $500,000, including all other previous approved requests and requests currently under review on this contract

This example demonstrates a Female, Nonsmoker, Age 65, who has a fixed premium, whole life policy with Cash Value and accelerates a portion of her Death Benefit under the Critical Illness Accelerated Death Benefit.

The Rider in this example pays a Critical Illness Accelerated Death Benefit Payment amount of $32,000. The amount payable reflects the deduction of a $250 administration processing fee and subtractions to reflect interest and our assessment of your future expected mortality Accelerated Death Benefit

Preconditions

You may elect to request a payment subject to the provisions of the Rider and the following conditions:

1. You must provide Us with the required certification of the illness; and

2. The contract to which the Rider is attached to must be in force at the time of Your request; and

3. The Death Benefit of such contract at the time Your request is received by Us, must be at least $25,000; and

4. We must receive the consent of all irrevocable Beneficiaries (if any) and all assignees (if any) in a form acceptable to Us

Present Value of the Requested Amount

The Accelerated Death Benefit Payment we make to You will be less than the amount of the Accelerated Death Benefit Request. The payment will be based on the present value calculation described in the Rider form.

Effect of the Rider on the Contract

The Death Benefit and Face Amount of the contract to which this Rider is attached will be reduced upon payment by the percentage of the Death Benefit accelerated. If applicable, the Payment must first be applied to a pro rata share of the outstanding debt The Cash Surrender Value, if any, Accumulation Value, if any, and Surrender Charge, if any will also be reduced by the percentage of the Death Benefit accelerated.

If the Requested Amount approved by Us is less than the full Death Benefit, the premium payable for such contract after the Payment will also be reduced The reduced premium will equal the appropriate premium rate applied to the reduced Face Amount plus any applicable contract fee. The cost of insurance, if any, will be calculated based on the reduced Face Amount.

However, if the reduced Face Amount of the contract is below the minimum face amount allowed when this contract was originally issued, the contract will terminate and We will pay to You any Cash Surrender Value associated with that reduced Face Amount (as applicable).

Upon request to accelerate the contract death benefits and upon the payment of the accelerated death

benefit, the Owner and any irrevocable Beneficiaries shall be given a statement demonstrating the effect of the acceleration of the payment of death benefits on the cash value, death benefit, premium COI charges, and policy loans (including policy liens) of the particular policy involved. The statement will display any premium or COI charges necessary to continue any remaining coverage following the acceleration and shall disclose all expense and interest charges associated with accelerating the death benefit. Statements for use with liens will state that future due and unpaid premiums or COI charges may be included in the lien if the provision so provides. The statement will be based only on guaranteed values. No projected or nonguaranteed values or benefits will be shown. The statement will include a disclosure that receipt of an accelerated death benefit may affect eligibility for Medicaid or other government benefits or entitlements and may have income tax consequences.

Premiums

There is no additional cost for the Rider prior to the payment.

Limitations

We will not make a payment under the Rider that is caused by, or contributed to, or results directly or indirectly from, a Suicide attempt or intentionally Self-Inflicted Injury while sane or insane within two (2) years after issue or reinstatement of this Rider

You may not make a request for an acceleration of the Death Benefit if You are:

1. required by law to use the payment to meet the claims of creditors, whether in bankruptcy or otherwise; or

2. required by a government agency to use the payment in order to apply for, obtain, or otherwise keep a government benefit or entitlement.

Acknowledgement

I(We), the undersigned, hereby acknowledge that I (We) have received the above Accelerated Death Benefit Disclosure Statement which was furnished to Me (Us) prior to the signing of the application for insurance.

Date

Signature of Insured (always required)

Printed Name of Proposed Insured

Date

Signature of Owner (if other than the Insured)

Printed Name of Owner

Date

Printed Name of Agent

Signature of Agent

This form can be used to accomplish a FULL or PARTIAL Exchange of policies pursuant to Internal Revenue Code (IRC) Section 1035.

Complete the requested information concerning the existing policy and contract, check the appropriate boxes, and date and sign this form. Refer to the application, and if applicable, prospectus and any state required forms for additional important disclosures and information. Check with both the receiving and surrendering company for form requirements specific to the transaction that is being initiated.

The receiving company may not accept the exchange if the funds do not meet its minimum premium requirements. The receiving company may not accept the rollover/transfer if the funds do not meet its minimum premium requirements.

Receiving Company Information

Surrendering Company Information

Complete one form for each surrendering company

1035 Exchange Details

Please confirm the availability of these options with both the surrendering and receiving company. Not all receiving companies provide life insurance products.

Full Exchange

Estimated Transfer Amount: $

If purchasing a Life Insurance policy, select any of the following that apply:

Loan Carry Forward

Loan Amount: $

Modified Endowment Contract

Partial Exchange (applicable to Annuity Contracts Only)

Type of Partial Exchange:

Specified Amount: $

Specified Percentage: %

Penalty Free Amount

This amount is subject to change base on the product provisions. Please check with the surrendering company to verify the amount.

Special Instructions for Liquidating Existing Contract

By executing this form, I authorize the full or partial liquidation of my existing contract or account in accordance with the sections completed above. I understand that fees and charges may apply if the transfer is processed before the maturity date. I hereby instruct the parties to process that liquidation:

Immediately—Waive any conservation period that may apply and process transfer request

At Maturity Date:

On a Specific Date:

Disclosures/Acknowledgements

I fully assign and transfer all claims, options, privileges, rights, title and interest to either all of the life insurance policy, all of the annuity contact or part of the annuity contract value identified in the Surrendered Policy / Contract Information section on Page 1 to the receiving company. The sole purpose of this assignment is to effect a tax-free exchange under Section 1035(a) of the Internal Revenue Code. All of the powers, elections, appointments, options and rights I have as owner of the contact, including the right to surrender, are now exercisable by the receiving company. Simultaneous with a full assignment, I also revoke all existing beneficiary designations under the Assigned Policy. Other than the above mentioned owner, no person, firm, or corporation other than myself and the insurer that issued the above numbered policy, has an interest in said policy. No proceedings in insolvency or bankruptcy have been instituted by or against me. I understand that the receiving company intends to surrender the contract for the cash value; or if this is a partial exchange, the portion assigned, subject to its terms and conditions, and to use the proceeds as the purchase payment for the new contract to be issued by the receiving company. I authorize the surrendering company to send the proceeds directly to the receiving company and understand that fees and surrender charges may apply. This exchange is subject to acceptance by the receiving company. The receiving company is not liable for changes in market value that may occur before the proceeds are received by the receiving company in good order and allocated to the new contract. Prior to the date of receipt of the proceeds by the receiving company, no value will accrue or be earned on the receiving company contract.

If this is a partial exchange, I understand that is subject to Revenue Ruling 2003-76, which dictates how much of the original contract’s cost basis must be allocated to the new contract. The cost basis should be allocated ratably between the two contracts based on the percentage of the value retained in the original contract and the percentage of the value transferred to the new contract. For example, if the contract value is $100,000 and basis is $50,000, and I assign 30% for a partial exchange, then $15,000 (30% of $50,000) of the basis would be applied to the new contract. I understand that the IRS has raised concerns about annuity contract owners using partial exchanges to avoid income tax, and I certify that I am not entering into this transaction for the purpose of reducing or avoiding income tax or the 10% penalty tax for early withdrawals.

I expressly represent that the sole purpose is to affect a partial 1035 exchange of an annuity contract. However, I acknowledge that Revenue Procedure 2011-38 states that withdrawals from annuitization, taxable owner or annuitant changes, or surrenders, other than an amount received as an annuity for a period of 10 years or more or during one or more lives, of either the original contract or the new contract during the 180 day period following the partial exchange, may affect the tax free status of the partial exchange.

Note: Other exceptions may apply and a subsequent direct transfer of all or a portion of either contract involved in the exchange could have tax and tax reporting consequences. Please consult your tax advisor. Please confirm with the carrier if they will support partial 1035 exchanges.

I acknowledge that the receiving company has made no representations concerning any tax treatment of this transaction. I understand that the receiving company has neither responsibility nor liability for the validity of this transaction or for my treatment under Section 1035(a) of the Internal Revenue Code or otherwise. Therefore, I agree to release and hold harmless the receiving company and its agents from any and all liability arising from, relating to, or in connection with, the taxation of a partial exchange of the above listed contact. I authorize the receiving company and the surrendering institution to share information necessary to maintain accurate records of the annuity cost basis and to ensure proper withholding and tax reporting. I have been directed to consult my tax or legal advisor before proceeding.

I authorize the receiving company to rely upon the cost basis information provide by the surrendering company, but agree that the receiving company will assume no responsibility for determining or verifying cost basis. If cost basis is not provided, I acknowledge that more restrictive or less beneficial tax rules may apply to the amounts transferred. I acknowledge that the receiving company provides this form and participates in this transaction as an accommodation to me. The receiving company does not give tax or legal advice on the tax consequences for replacing one contract for another, and assumes no responsibility or liability for the validity of this assignment or for the tax treatment of this exchange under IRC Section 1035(a) or other laws or regulations.

I agree that if the receiving company, in its sole discretion, determines that it is unlikely to receive timely payment of the full contract cash surrender values, the receiving company my reassign ownership of the policy/contract back to me.

LOAN CARRY FORWARD IF THE BOX IN THE 1035 EXCHANGE DETAILS SECTION IS NOT CHECKED, THE RECEIVING COMPANY WILL ASSUME THAT THE LOAN(S) IS/ARE NOT TO BE CARRIED FORWARD. If this box is checked, I request that the policy to be issued by the receiving company be subject to indebtedness equal to the loan on the existing policy. I acknowledge that when issued, the provisions of the receiving company policy will apply to the indebtedness and that the benefits and values of that policy will be reduced accordingly for the amount loaned and interest. I understand that the receiving company may not process this request prior to issuing a policy under the following conditions: Surrender value is insufficient as determined by the receiving company policy’s specifications or the existing insurer does not provide confirmation of cost basis with acknowledgement of loan carried forward.

RETURN OF LIFE INSURANCE POLICY OR ANNUITY CONTRACT Does not apply to partial 1035 exchanges on annuity contracts. Unless the surrendering company’s policy or contract is attached, I affirm that the policy or contract has been destroyed or lost and that reasonable effort has been made to locate it. To the best of my knowledge no one else has any right, title or interest in the contract, nor has it been assigned, pledged or encumbered, unless this is a life insurance policy with a loan to carry forward.

MAXIMUM ISSUE AGE DISCLOSURE An annuity contract may not be issued should the funding requirements be received after reaching maximum issue age for the annuity contract applied for. If the funds are received after the maximum issue age, the contract may be rejected and the funds returned to their original source. The surrendering company may or may not take the funds back, which could result in a taxable event.

The IRS has provided limited guidance on the tax consequences of transferring a life insurance policy with values less than the investment in the contract to a new or existing annuity contract. If the owner surrenders the newly acquired annuity contract, it is not clear whether the annuity losses are fully deductible against ordinary income or deductible as a miscellaneous deduction subject to a limitation of 2% of adjusted gross income (AGI). If the IRS views the two transactions as a single integrated transaction, they could consider it a step transaction and successfully disallow the losses as a tax deduction.

Taxpayer Identification Number Certification

Under penalties of perjury, I certify that:

1. The number on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and

3. I am a U.S. person (including a U.S. resident alien).

Check this box if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return.

Signatures

This transfer request also authorizes the receiving company to request information on the status of this transfer or exchange by phone or in writing. By signing below, I represent that the responses here in are, to the best of my knowledge, accurate and I have read the DISCLOSURES / ACKNOWLEDGEMENTS on page 3 of this form.

The Internal Revenue Service does not require your consent to any provisions of this document other than the certifications required to avoid backup withholding.

Signature of Owner/Plan Administrator/Trustee/Custodian

Date

Signature of Joint Owner

Date

Signature of Insured/Annuitant (if applicable)

Date

Signature of Spouse (Required in AZ, CA, ID, LA, NV, NM, TX, WA, and WI only)

Date

Make a Difference: One Member

I (We) declare my(our) desire(s) to become a member of GBU Financial Life (GBU) to share in the common bond of supporting local communities in the areas of wellness, education, charitable giving and hometown heroes. In addition to the financial security offered by the product, I understand becoming a member entitles me to all the applicable benefits, programs, rights and privileges GBU offers all its insured members.

As a welcome to your membership, GBU will make a $50 donation to one of the following organizations you select. Please choose from the below list:

DonorsChoose® (Education) donorschoose.org

Mission Statement: To make it easy for anyone to help a teacher in need, moving us closer to a nation where students in every community have the tools and experiences they need for a great education.

Mothers Against Drunk Driving® (MADD) (Education) madd.org

Mission Statement: To end drunk driving, help fight drugged driving, support the victims of these violent crimes and prevent underage drinking.

American Cancer Society® (Wellness) cancer.org

Mission Statement: To improve the lives of people with cancer and their families through advocacy, research and patient support to ensure everyone has an opportunity to prevent, detect, treat and survive cancer.

Ronald McDonald House Charities | RMHC® (Wellness) rmhc.org

Mission Statement: To create, find and support programs that directly improve the health and well-being of children and their families.

American Red Cross (Hometown Heroes) redcross.org

Mission Statement: To prevent and alleviate human suffering in the face of emergencies by mobilizing the power of volunteers and the generosity of donors.

Operation Troop Appreciation (Hometown Heroes)

operationtroopappreciation.org

Mission Statement: To build and sustain the morale and well-being of the military community, past and present, with the assurance that the American public supports and appreciates their selfless service and daily sacrifices.

Feeding America® (Charitable Giving)

feedingamerica.org

Mission Statement: To advance change in America by ensuring equitable access to nutritious food for all in partnership with food banks, policymakers, supporters and the communities we serve.

Marine Toys for Tots Foundation (Charitable Giving) toysfortots.org

Mission Statement: To help less fortunate children throughout the United States experience the joy of Christmas; to play an active role in the development of one of our nation’s most valuable resources—our children; to unite all members of local communities in a common cause for three months each year during the annual toy collection and distribution campaign; and to contribute to improving communities in the future.

If an organization is not selected, your donation will be made to the GBU Foundation which provides educational scholarships and grants to GBU members.

Application for Spousal Rider to Individual Life Insurance

1.

Agreement – Authorization – Acknowledgement

This authorization complies with the HIPAA Privacy rule.

I understand I may revoke this authorization at any time, except to the extent that action has been taken in reliance on this authorization. Written notice must be sent to GBU Financial Life, 4254 Saw Mill Run Blvd., Pittsburgh, PA 15227-3394. I, the Proposed Insured (and any Payor or Owner signing below), by my signature set forth hereafter

a) All statements and answers in this application are complete and true to the best of my knowledge and belief.

b) Except as stated in the Conditional Receipt, no insurance will take effect unless the first full premium is paid and policy is delivered while the health of any Proposed Insured continues, without any material change, to be as represented in this application.

c)

No agent has authority to waive any answer; otherwise modify this application; or bind GBU Financial Life, hereinafter called “Company,” in any way by making any promise or representation which is not set out in writing in this application.

d)

$ has been deposited toward payment of the first premium on the policy. The terms of the Conditional Receipt received for that premium deposit are accepted.

I AUTHORIZE any physician; medical practitioner; hospital; clinic; other medical or medically related facility; to give the Company or its reinsurer(s) all information it holds that pertains to medical consultations; treatments; surgeries; and hospital confinements which relate to the physical and mental condition of myself or my minor children. This authorization also includes a pharmacy benefits manager; insurance support organization; pharmacy/government agency; insurance or reinsuring company; MIB, Inc. (“MIB”); consumer reporting agency; or any other organization; institution; or person. This authorization also includes information about drugs and alcoholism or any other non-health (non-medical) history information.

I authorize the Company or its reinsurers to release any information including my personal health information obtained to reinsuring companies; MIB; or other persons or organizations performing business or legal services in connection with my application or claim. I further authorize the Company and its reinsurers to release any information that may be otherwise lawfully required or as I may further authorize. As to this authorization, I agree that a photographic copy will be valid as the original and that it will be valid for 30 months from the date shown below. This time limit is permitted by applicable law in the state where the policy is delivered or issued for delivery.

I know examiners, reinsurers, attorneys or other medical directors may disclose such health information for purposes of underwriting, compliance, record clarification or explanation. The aforementioned parties may also disclose such information in response to litigation, summons or subpoenas. I understand that after this information is disclosed the recipient may re-disclose it resulting in loss of protection by federal regulations.

I understand that there are limitations on my right to revoke this authorization. Any action taken in reliance on this authorization will be valid if such action has been taken prior to receipt of notice of revocation. If this authorization is used to collect information in connection with a claim for benefits, it will be valid for the duration of the claim. If the law of my state so provides, my authorization may not be revoked during a contestable investigation.

I also understand that my revocation of this authorization will not result in the deletion of codes in the MIB databases if such codes are reported by the Company or its reinsurers (or the Company or its reinsurers becomes obligated to report such codes to MIB) while this authorization is in force.

I may refuse to sign this authorization and understand that my refusal to sign will affect my ability to obtain life insurance coverage.

I ACKNOWLEDGE receipt of the following notices:

a) “Notice of Information Practices” required by Public Law 91-508 and other information practices, statutes, and

b) Notification regarding MIB, Inc

Agreement – Authorization – Acknowledgement (continued)

I (We) declare that the Proposed Insured desires to unite with GBU members for the following reasons. (a) Financial security and fraternal benefits. (b) Charitable community involvement. (c) Share the appreciation of our members’ culture and heritage. (d) Meet any other requirements for membership established by GBU By purchasing an insurance product from GBU Financial Life, the Proposed Insured gains automatic membership in the society including all of its rights and privileges.

GBU Financial Life is licensed to do business in this state. As a not-for-profit organization, fraternal benefit societies are not included in the State Guaranty Association. This means that fraternal benefit societies cannot be assessed for the insolvency of other life insurers or other fraternal benefit societies. By law a fraternal benefit society is responsible for its own solvency. If there is an impairment of reserves, a certificate holder may be assessed a proportionate share of the impairment. This process is described in the certificate issued by the society.

I ACKNOWLEDGE that I did not receive a sales illustration containing full disclosure at the time when I completed the life insurance application. I understand that when the policy is issued, such an illustration will be provided to me at the time the policy is delivered to me.

Fraud Warning. Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under the state law.

Dated at _____ ___________, ____ ____, on __________________________, 20 City State

Investigative Consumer Reports

Under Public Law 91-508, we are required to inform persons proposed for insurance that, as part of our regular underwriting procedure, an investigative consumer report may be obtained which will provide applicable information concerning character, general reputation, personal characteristics, and mode of living. This information will be obtained through personal interviews with your friends, neighbors, and associates.

Important Notice

The underwriting process (evaluation and classification of risks) is necessary to assure reasonable cost of insurance and provide a mechanism by which policyholders pay their fair share of the cost. In considering your application, information from various sources is considered, including your own statements, the results of your physical examination (if required), and any reports we obtain from doctors or medical facilities where you have been treated.

NOTIFICATION REGARDING MIB, Inc. (“MIB”): Information regarding your insurability will be treated as confidential. GBU Financial Life or its reinsurers may, however, make a brief report thereon to the MIB. The MIB is a not-for-profit membership organization of insurance companies operating an information exchange on behalf of its members. The MIB may also release information in your file to another MIB-member company to whom application may be made for life or health insurance coverage; or, a benefit claim is submitted.

Upon receipt of a request from you, MIB will arrange disclosure of any information it may have in your file. Please contact the MIB at 866-692-6901. If you question the accuracy of information in MIB’s file; you may contact MIB and seek a correction in accordance with the procedures set forth in the Federal Fair Credit Reporting Act. MIB’s information office address: 50 Braintree Hill Park, Suite 400, Braintree, MA 02184-8734

GBU Financial Life or its reinsurers may also release information in its file to other insurance companies to whom you may apply for life or health insurance; or, to whom a claim for benefits may be submitted. Information for consumers about the MIB may be obtained at its website www.mib.com.

THIS NOTIFICATION MUST BE GIVEN TO THE PROPOSED INSURED BEFORE THE APPLICATION IS COMPLETED.

Application for Children’s Term Rider to Individual Life Insurance

1. Owner Legal Name (First, Middle Initial, Last)

Social Security Number Phone

2. Insurance

Applied For Plan CHILDREN’S TERM RIDER

3. List All Children to be Covered Under This Rider

4. Health

5. Details to Any “Yes”

Answers in Question 4.

Child

Face Amount: $

of Birth Gender Social Security No. Height and Weight / / / / / /

a) Has every child proposed for coverage had a routine physical exam by a licensed medical professional within the 24 months prior to the date of this application? If not, please provide details in Question 5 below. Yes No

b) Was any child born prematurely or with abnormalities at birth diagnosed by a medical professional? Yes No

c) Has any child been treated or diagnosed by a physician for Attention Deficit Hyperactivity Disorder (ADHD), Depression or Anxiety, Diabetes, Cystic Fibrosis, kidney disorder, respiratory disorder, heart disease or disorder, mental disease or disorder, cancer or any other impairment or disease? Yes No

d) Within the last 5 years, has any child proposed for coverage been treated or diagnosed by a member of the medical profession for any other condition that is not disclosed above? Yes No

Please provide additional details to include: Name, Illness, Date, Names and Addresses of Doctors/Hospitals Consulted and Degree of Recovery:

Agreement—Authorization—Acknowledgement

This authorization complies with the HIPAA Privacy rule.

I understand I may revoke this authorization at any time, except to the extent that action has been taken in reliance on this authorization. Written notice must be sent to GBU Financial Life, 4254 Saw Mill Run Blvd., Pittsburgh, PA 15227-3394. I, the Proposed Insured (and any Payor or Owner signing below), by my signature set forth hereafter

AGREE to the following:

a) All statements and answers in this application are complete and true to the best of my knowledge and belief.

b) Except as stated in the Conditional Receipt, no insurance will take effect unless the first full premium is paid and policy is delivered while the health of any Proposed Insured continues, without any material change, to be as represented in this application.

c) No agent has authority to waive any answer; otherwise modify this application; or bind GBU Financial Life, hereinafter called “Company,” in any way by making any promise or representation which is not set out in writing in this application.

d) $ has been deposited toward payment of the first premium on the policy. The terms of the Conditional Receipt received for that premium deposit are accepted.

I AUTHORIZE any physician; medical practitioner; hospital; clinic; other medical or medically related facility; to give the Company or its reinsurer(s) all information it holds that pertains to medical consultations; treatments; surgeries; and hospital confinements which relate to the physical and mental condition of myself or my minor children. This authorization also includes a pharmacy benefits manager; insurance support organization; pharmacy/government agency; insurance or reinsuring company; MIB, Inc. (“MIB”); consumer reporting agency; or any other organization; institution; or person. This authorization also includes information about drugs and alcoholism or any other non-health (non-medical) history information.

I authorize the Company or its reinsurers to release any information including my or my minor children’s personal health information obtained to reinsuring companies; MIB; or other persons or organizations performing business or legal services in connection with my application or claim. I further authorize the Company and its reinsurers to release any information that may be otherwise lawfully required or as I may further authorize. As to this authorization, I agree that a photographic copy will be valid as the original and that it will be valid for 24 months from the date shown below. This time limit is permitted by applicable law in the state where the policy is delivered or issued for delivery.

I know examiners, reinsurers, attorneys or other medical directors may disclose such health information for purposes of underwriting, compliance, record clarification or explanation. The aforementioned parties may also disclose such information in response to litigation, summons or subpoenas. I understand that after this information is disclosed the recipient may re-disclose it resulting in loss of protection by federal regulations.

I understand that there are limitations on my right to revoke this authorization. Any action taken in reliance on this authorization will be valid if such action has been taken prior to receipt of notice of revocation. If this authorization is used to collect information in connection with a claim for benefits, it will be valid for the duration of the claim. If the law of my state so provides, my authorization may not be revoked during a contestable investigation.

I also understand that my revocation of this authorization will not result in the deletion of codes in the MIB databases if such codes are reported by the Company or its reinsurers (or the Company or its reinsurers becomes obligated to report such codes to MIB) while this authorization is in force.

I may refuse to sign this authorization and understand that my refusal to sign will affect my ability to obtain life insurance coverage.

I ACKNOWLEDGE receipt of the following notices:

a) “Notice of Information Practices” required by Public Law 91-508 and other information practices, statutes, and

b) Notification regarding MIB, Inc

Agreement—Authorization—Acknowledgement (continued)

I (We) declare that the Proposed Insured desires to unite with GBU members for the following reasons. (a) Financial security and fraternal benefits. (b) Charitable community involvement. (c) Share the appreciation of our members’ culture and heritage. (d) Meet any other requirements for membership established by GBU. By purchasing an insurance product from GBU Financial Life, the Proposed Insured gains automatic membership in the society including all of its rights and privileges.

GBU Financial Life is licensed to do business in this state. As a not-for-profit organization, fraternal benefit societies are not included in the State Guaranty Association. This means that fraternal benefit societies cannot be assessed for the insolvency of other life insurers or other fraternal benefit societies. By law a fraternal benefit society is responsible for its own solvency. If there is an impairment of reserves, a certificate holder may be assessed a proportionate share of the impairment. This process is described in the certificate issued by the society.

I ACKNOWLEDGE that I did not receive a sales illustration containing full disclosure at the time when I completed the life insurance application. I understand that when the policy is issued, such an illustration will be provided to me at the time the policy is delivered to me.

Fraud Warning. Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under the state law.

Dated at ______ ___________, ____ _, on __________________________, 20 City State _ ___________________________________________

Investigative Consumer Reports

Under Public Law 91-508, we are required to inform persons proposed for insurance that, as part of our regular underwriting procedure, an investigative consumer report may be obtained which will provide applicable information concerning character, general reputation, personal characteristics, and mode of living. This information will be obtained through personal interviews with your friends, neighbors, and associates.

Important Notice

The underwriting process (evaluation and classification of risks) is necessary to assure reasonable cost of insurance and provide a mechanism by which policyholders pay their fair share of the cost. In considering your application, information from various sources is considered, including your own statements, the results of your physical examination (if required), and any reports we obtain from doctors or medical facilities where you have been treated.

NOTIFICATION REGARDING MIB, Inc. (“MIB”): Information regarding your insurability will be treated as confidential. GBU Financial Life or its reinsurers may, however, make a brief report thereon to the MIB. The MIB is a not-for-profit membership organization of insurance companies operating an information exchange on behalf of its members. The MIB may also release information in your file to another MIB-member company to whom application may be made for life or health insurance coverage; or, a benefit claim is submitted.

Upon receipt of a request from you, MIB will arrange disclosure of any information it may have in your file. Please contact the MIB at 866-692-6901. If you question the accuracy of information in MIB’s file; you may contact MIB and seek a correction in accordance with the procedures set forth in the Federal Fair Credit Reporting Act. MIB’s information office address: 50 Braintree Hill Park, Suite 400, Braintree, MA 021848734.

GBU Financial Life or its reinsurers may also release information in its file to other insurance companies to whom you may apply for life or health insurance; or, to whom a claim for benefits may be submitted. Information for consumers about the MIB may be obtained at its website www.mib.com

THIS NOTIFICATION MUST BE GIVEN TO THE PROPOSED INSURED BEFORE THE APPLICATION IS COMPLETED.